Va Form 10-0485 - Request For And Authorization To Release Protected Health Information To Nationwide Health Information Network


Request for and Authorization to Release Protected Health Information to
Nationwide Health Information Network
Privacy Act Information: The execution of this form does not authorize the release of information other than that
specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form
authorizes release of information in accordance with The Health Insurance Portability and Accountability Act,
(HIPAA) 45 CFR Parts 160 and 164, 5 U.S.C. 552a, and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure
of the Information requested on this form is voluntary. However if the information containing last four of the Social
Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and
accurately, Nationwide Health Information Network will be unable to comply with the request. The Veterans Health
Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization. VA may
disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the
information as outlined in the Privacy Act systems of records notices identified as 24VA19 "Patient Medical Record -
VA" and in accordance with the VHA Notice of Privacy Practices. You do not have to provide the information to VA,
but if you do not the Nationwide Health Information Network exchange will be unable to process your request and
serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which
you may be entitled. VA may also use this information on this form to identify Veterans and persons claiming or
receiving VA benefits and their records, and for other purposes authorized or required by law.
Patient Full Name
Last: (print)
Last four digits of SSN:
Requestor Name:
VA Approved Nationwide Health Information Network Participants
Information Requested:
Pertinent health information from electronic health record.
I request and authorize my VA health care facility to release my protected health information (PHI) for treatment
purposes only to the communities that are participating in the Nationwide Health Information Network (NwHIN). This
information may consist of the diagnosis of Sickle Cell Anemia, the treatment of or referral for Drug Abuse, treatment
of or referral for Alcohol Abuse or the treatment of or testing for infection with Human Immunodeficiency Virus. This
authorization covers the diagnoses and related health information that I may have upon signing of the authorization
and the diagnoses and the related health information that I may acquire in the future, including those protected by 38
U.S.C. 7332.
This authorization will remain in effect for the period of five years. I may revoke this authorization through the
eBenefits portal, or in writing at my Release of Information (ROI) unit at the VA health care facility housing my
records, at any time, except to the extent that action has already been taken to comply with it. Written revocation is
effective upon receipt by the Release of Information (ROI). Re-disclosure of my electronic health records by those
receiving the information may be accomplished without my further authorization and may no longer be protected.
AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the
information given above is accurate and complete to the best of my knowledge.
Signature of Patient
OCT 2011


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Parent category: Legal